Evaluating Upper Limb Motor Control after Tendon Transfer and Task-Based Therapy

描述(由申请人提供)： 拟议的试点项目是朝着更广泛的目标迈出的关键一步，目的是改善四肢瘫痪肌腱转移术的功能结果。肌腱移植是一种外科手术，在这种手术中，自愿控制的肌肉(供体肌肉)的肌腱从其附着处松开，并通过外科手术连接到瘫痪肌肉的肌腱上，以恢复因瘫痪而丧失的功能。接受这些程序的人必须学会自愿地在新的解剖位置激活被转移的肌肉，更重要的是在功能任务执行期间与新的协作剂协调。然而，在手术和传统护理之后，个体并没有完全激活被转移的肌肉来执行其新的功能。因此，有可能推进康复计划，通过肌肉再教育和训练计划改善术后表现，从而改善手术结果。了解运动计划和控制策略如何决定术后上肢功能，对于客观评估当前和未来的干预方案至关重要。这个试点项目的目标是评估基于任务的家庭治疗方案的有效性，该方案遵循肌腱移位以恢复侧向捏合力和常规治疗。预计基于任务的计划将解决转移后的运动学习，并导致转移的肌肉作为协调上肢运动的一部分而得到更好的自愿激活，这对于在功能姿势中产生夹紧力非常重要。目前，患者必须在接受有针对性的再培训计划之前出院。据认为，在功能性姿势中，可测量到的转移肌肉激活的增加将转化为上肢运动能力的改善。研究的具体目标是：1.使用临床结果测量方法，比较参与前后的等长捏紧力大小、执行选定捏捏任务的能力以及自我感觉的表现，来评估所建议的任务型家庭治疗计划的有效性。2.评估被转移BR的运动控制与训练相关的变化。肌内肌电将被记录下来，以比较在不同上肢功能姿势下屈肘和捏肘时被转移的BR和其他肘屈肌的激活情况。肌电将根据其大小进行量化，并通过使用EMG分解来提取活跃运动单元的招募和激发模式。3.评估任务型治疗对手术结果不同的参与者的影响，以确定哪些人将从任务型治疗中受益，并确定导致运动能力变化的机制。这项工作的最终目标是提供证据，证明基于任务的计划应该成为接受肌腱转移手术的个人标准术后康复的一部分。更有效的术后康复计划将改善肌腱移植后的长期功能结果，并旨在对急性和慢性脊髓损伤患者有效。这些数据将被用于更广泛的研究设计，以对重点康复干预的效果进行前瞻性调查。建议的期限为 这项试点研究为期两年。从拟议的初步研究中获得的信息将被用来开发假设和统计能力，以指导一项全面研究，以评估通过基于任务的培训改善肌腱转移手术结果的能力。 公共卫生相关性： 退伍军人事务部帕洛阿尔托医疗保健系统，脊髓损伤服务的使命是“提供全面的治疗，以最大限度地提高功能独立性，提高生活质量，并帮助个人恢复和保持他或她在社会中的角色。”在美国超过10万名脊髓损伤导致四肢瘫痪的人中，22%是退伍军人。在这些患者中，上肢功能的恢复排在比膀胱、肠道和性功能更高的位置，是康复的一个重要目标，这将导致医疗成本的降低和生活质量的提高。这项拟议的试点研究旨在通过评估肌腱移位和传统疗法后基于任务的治疗方案的有效性，来检查恢复上肢功能的传统方法的必要性。这项研究将有助于理解决定上肢功能的运动学习策略，并可能导致基于证据的康复方案，以改善四肢瘫痪患者的上肢功能。

DESCRIPTION (provided by applicant): The proposed pilot project is a critical step towards the broader objective to improve functional outcomes of tendon transfer procedures in tetraplegia. Tendon transfers are surgical procedures in which the tendon of a muscle under voluntary control (donor muscle) is released from its insertion and is surgically attached to the tendon of a paralyzed muscle in order to restore function lost to paralysis. Individuals who undergo these procedures must learn to voluntarily activate the transferred muscle in its new anatomical location and more importantly to coordinate with new synergists during functional task performance. However, after surgery and conventional care, individuals do not fully activate the transferred muscle to perform its new function. Thus there is potential to advance rehabilitation programs that will improve surgical outcomes by improving postoperative performance with a muscle re-education and training program. Understanding how motor planning and control strategies determine postoperative upper limb function is essential for objective evaluation of current and prospective intervention protocols. The goal of this pilot project is to evaluate the effectiveness of a task-based home therapy program that follows tendon transfer to restore lateral pinch strength and conventional therapy. It is expected that a task-based program will address motor learning after transfer and result in improved voluntary activation of the transferred muscle as part of coordinated upper limb movements, important for producing pinch force in functional postures. Currently, patients must be discharged prior to receiving a focused re-training program. It is proposed that measurable increases in transferred muscle activation in functional postures will translate to improved upper limb performance. The specific objectives are to: 1. Evaluate the effectiveness of the proposed task-based home therapy program using clinical outcome measures to compare isometric pinch force magnitude, the ability to perform selected pinch tasks, and self- perceived performance before and after participation. 2. Assess training-related changes in the motor control of the transferred Br. Intramuscular EMG will be recorded to compare the activation of the transferred Br and the other elbow flexors during elbow flexion and pinch in various functional upper limb postures. The EMG will be quantified in terms of its magnitude and by using EMG decomposition to extract the recruitment and firing patterns of the active motor units. 3. Assess the effects of a task-based therapy for participants with different surgica outcomes to determine which individuals will benefit from task-based therapy and identify the mechanisms responsible for changes in motor performance. The ultimate goal of this work is to provide evidence that a task-based program should become part of the standard post-operative rehabilitation for individuals who receive tendon-transfer surgery. A more effective post-surgical rehabilitation program will lead to improved long-term functional outcomes following tendon- transfer and is intended to be effective in patients with both acute and chronic spinal cord injuries. These data will be used towards a broader study design for a prospective investigation of the effects of a focused rehabilitation intervention. The proposed time period for this pilot study is two years. Information gained from the proposed pilot study will be used to develop hypotheses and statistical power to guide a full-scale study to evaluate the capacity for improving tendon transfer surgical outcomes through task-based training. PUBLIC HEALTH RELEVANCE: The mission of the VA Palo Alto Health Care System, Spinal Cord Injury Service is "to provide comprehensive treatment to maximize functional independence, enhance quality of life, and assist the individual regain and maintain his or her role in society." Of the over 100,000 individuals in the United States who have spinal cord injuries resulting in tetraplegia, 22% are veterans. Recovery of upper limb function has been ranked higher than bladder, bowel, and sexual function in this patient population and is an important goal in rehabilitation that will reslt in decreased medical costs and improved quality of life. The proposed pilot study addresses the need to examine traditional approaches to restoring upper limb function by evaluating the effectiveness of a novel task-based therapy program after tendon transfer and conventional therapy. This study will contribute to understanding the motor learning strategies that determine upper limb function and may lead to evidence- based rehabilitation protocols for improving upper limb performance in tetraplegia.